A rest home must apologise after a man in its care with Alzheimer's and dementia fell 97 times in 10 months - despite the operator being warned of his risk of falling.
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The Health and Disability Commissioner has criticised Radius Residential Care for not taking sufficient action to reduce the man's risk of falling and said there were failures of care and inadequate supervision.
The family of the man - who is not identified to protect his privacy - told Radius Care when he was admitted that he had a high risk of falling.
His Alzheimer's disease, macular degeneration and severe advanced dementia was known. He was also assessed as being mentally incapable.
Despite this warning, the man fell 97 times in 10 months, but only 55 of these were reported on an incident form, and next of kin was only notified about 23 falls.
One day the man was found on a road near the rest home, and staff had not noticed he had even left. He was found and returned by staff but 10 minutes later he left again.
Deputy commissioner Rose Wall said Radius Residential Care did not provide the man with reasonable care and skill, and breached the Code of Health and Disability Services Consumers' Rights.
She also criticised poor communication from Radius to the man's family.
She has made a number of recommendations, including that Radius provide evidence its policies and procedures on fall management are best practice, that they provide evidence of audits on their policies, and that they apologise to the man's family.
